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PL BLICHE ,.LTH sERVICE <br />I ‘ •.. <br />Karen Furst, M.D., NI.P.H., Health Officer <br />, nArl IIA' <br />304 East Weber Avenue, Third Floor • Stockton, CA 95202 <br /> <br />209/468-3420 <br />VERIFICATION OF COMPLIANCE WITH CALIFORNIA HEALTH AND <br />SAFETY CODE, SECTION 116049.1 (a-f) <br />SAN JOAQUIN <br />ENVIRONMENTAL HEALTH <br />COUNTY <br />DIVISION <br /> ,•r: <br />?••• <br />' <br />--,..e---' 0\ c., <br />-1 .<i — <br />yy. <br />Signature <br />Zip q9C--/k1 <br /> <br />Site address of pool(s) <br />. Number of swimming pools, spa pools, wading pools or special purpose pools at the site <br />I verify that I am the owner/home owner association president/legally responsible person for the <br />above named pool(s) and that I had the pool(s) inspected for compliance with Section 116049.1 <br />of the California Health and Safety Code. <br />Pr-int name ó4 +A/9,i FA) <br />Telephone <br />There is no pool light in this/these pool(s). Indicating there is no pool light means there <br />is no light fixture, light casing, or recessed light niche, whether working or not <br />working, within the confines of the pool shell. <br />Please attach a copy of the completed and signed inspection permit or report from the local <br />building department or the qualified contractor and send to: <br />San Joaquin County <br />Public Health Services <br />Environmental Health Division <br />Recreational Health Program <br />304 East Weber Avenue, Third Floor <br />Stockton, CA 95202 <br />4 i <br />!oaquirl Courizy i.--:.ralt11 Care 5er.-.L:c.s <br />e Date